lecture for MBBS students, topic includes rheumatoid arthritis, ankylosing spondylitis, gout, pseudo gout, psoriatic arthritis, ocronosis, hemophilic arthritis and neuropathic arthritis.

1. INFLAMMATORY ARTHRITIS
Dr. LOKESH CHUGH
SENIOR RESIDENT
DEPTT. OF ORTHOPAEDICS

2. TOPICS TO BE DISCUSSED
• RHEUMATOID ARTHRITIS
• ANKYLOSING SPONDYLITIS
• GOUT
• PSEUDOGOUT
• PSORIATIC ARTHROPATHY
• ALKAPTONURIC ARTHROPATHY
• HAEMOPHILIC ARTHROPATHY
• NEUROPATHIC ARTHROPATHY

3. TYPES OF ARTHRITIS
MONOARTICULAR
• SEPTIC ARTHRITIS
(PYOGENIC/TUBERCULAR)
• HAEMOPHILIC ARTHRITIS
• SECONDARY TO ANY
TRAUMA OR INFECTION-
SECONDARY ARTHRITIS
POLYARTICULAR
• RHEUMATOID ARTHRITIS
• RHEUMATIC FEVER
• JUVENILE CHRONIC
POLYARTHRITIS
• PRIMARY OSTEOARTHRITIS
• SERONEGATIVE
SPONDYLOARTHRITIS

4. RHEUMATOID ARTHRITIS
• Chronic multisystem disease
• Non-suppurative inflammation of synovial
joint
• Etiology – unknown/ idiopathic
• Associated with HLA-DR4/ HLA- DR 1
• Mycoplasma, clostridium, EB virus

5. DIAGNOSTIC CRITERIA
• AMERICAN RHEUMATISM ASSOCIATION ,
1987 laid down criteria, according to which
there are total of 7 points.
• 4 out of 7 confirms diagnosis of RA.
• Sensitivity of 93% and specificity of 90 percent

6. American Rheumatism Association
criteria for RA
1) morning stiffness in and around joints lasting at least
1 hour before maximal improvement
2) soft tissue swelling (arthritis) of 3 or more joint areas
observed by a physician
3) swelling (arthritis) of the proximal interphalangeal,
metacarpophalangeal, or wrist joints
4) symmetric swelling (arthritis)
5) rheumatoid nodules
6) the presence of rheumatoid factor
7) radiographic erosions and/or periarticular osteopenia
in hand and/or wrist joints.

7. EULAR SCORING
• In 2010 the ACR and the European League
Against Rheumatism (EULAR)
• Emphasis RA characteristics that emerge early
in the disease course, including ACPAs, a
biomarker that predicts aggressive disease.

8. EULAR SCORE FOR RA
• JOINT INVOLVEMENT ( SMALL MULTIPLE
JOINTS – MORE SCORE)
• SEROLOGY (RA FACTOR, ANTI CCP ANTIBODY)
• ACUTE PHASE REACTANTS ( ESR, CRP)
• DURATION OF SYMPTOMS (6 WEEKS OR
MORE)
• 6 OR MORE SCORE IS DIAGNOSTIC FOR
RHEUMATOID ARTHRITIS

10. PATHOGENESIS
• IMMUNE COMPLEX FORMATION
• CHRONIC GRANULOMATOUS INFLAMMATION
OF SYNOVIAL MEMBRANE
• SYNOVIAL HYPERTROPHY
• ARTICULAR CARTILAGE LOOSE ITS SMOOTH
SHINY APPEARANCE – PANNUS FORMATION
AT PERIPHERY

11. • ARTICULAR EROSION- PAIN , MUSCLE SPASM
• JOINT EROSION – DEFORMITY DEVELOPS-
LATER STAGES.
• FIBROUS / BONY ANKYLOSIS CAN ALSO
DEVELOP WHERE ADHESIONS DEVELOP
BETWEEN APPOSING LAYERS OF PANNUS.

12. PATHOGENESIS

13. CLINICAL FEATURES
• 20-50 YEARS
• FEMALE PREDOMINANT 3:1
• PAIN, EARLY MORNING STIFFNESS IN MCP
JOINTS BILATERAL HANDS, PIP BILATERAL
FINGERS
• +/- FEVER

14. DEFORMITIES IN RA
• ULNAR DRIFT OF HAND
• BOUTONNIERE DEFORMITY
• SWAN NECK DEFORMITY
• HALLUX VALGUS
• HAMMER TOE
• EQINUS AT ANKLE
• KNEE- FLEXION, POSTERIOR SUBLUXATION,
EXTERNAL ROTATION DEFORMITY

15. EXTRA ARTICULAR MANIFESTATIONS
• VERY COMMON
• SOMETIMES TELL ABOUT PROGNOSIS OF
DISEASE

16. • VASCULITIS- ARTERITIS
• RHEUMATOID NODULES- OLECRANON, TA
• SEROSITIS
LUNG, PLEURA
HEART- CARDIOMYOPATHY
EYE- IRIDOCYCLITIS
NERVOUS SYSTEM- CARPAL TUNNEL SYNDROME
• OTHERS- ANAEMIA

17. INVESTIGATIONS
• X RAY
• REDUCED JOINT SPACE
• EROSION OF ARTICULAR MARGINS
• SUBCHONDRAL CYSTS
• SOFT TISSUE SHADOW AT LEVEL OF JOINT
• LATER STAGES- DEFORMITIES OF HAND

18. BLOOD INVESTIGATIONS
• ESR RAISED
• LOW HEMOGRAM
• RHEUMATOID FACTOR POSITIVE
• Anti CCP POSITIVE (anti cyclic citrullinated
peptide)

19. DIFFERENTIAL DIAGNOSIS
• SLE- NON SYMMETRICAL
• OSTEOARTHRITIS- MORE THAN 55 OR 60
LACK ANY SYSTEMIC FEACTURES, FEVER, WEIGHT
LOSS
DISTAL IP JOINTS INVOLVED
DURATION OF MORNING STIFFNESS LESS AS
COMPARED TO RA
• PSORIATIC ARTHRITIS- DIP INVOVED, PSORIATIC
LESION AT SKIN AND NAIL

20. TREATMENT
• INDUCTION OF REMISSION AND
MAINTENANCE – MEDICATIONS
NSAIDS
DMARDS- MTX, SAAZ, LEFLUNOMIDE (LFT 6
WEEKLY)
STEROIDS
BIOLOGICS – TOFACITINIB (JAK inhibitor)

21. DMARDS
• HCQ 200mg BD ; skin pigmentation,
retinopathy, myopathy, psychosis
• Methotrexate 7.5 to 20 mg once weekly ;
hepatotoxic, hair loss, bone marrow
suppression. Add folvite 5 mg OD.
• Sulfasalazine 2gm OD; rash, hepatotoxic
• Leflunomide 10-20 mg OD after 100mg od for
3 days induction; hepatotoxic

22. BIOLOGICS
• Anti TNF alfa agents ; infliximab, adalimumab
• IL 6 Antagonist ; Tocilizumab
• Anti CD 20 antibody ; rituximab
• T cell inhibitor ( selective costimulatory
inhibitor) ; Abatacept

23. • PRESERVATION OF JOINT FUNCTION
PHYSIOTHERAPY
REST/ SPLINTAGE- ACUTE PHASE
HOT FOMENTATION/ WAX BATH
JOINT MOBILIZATION EXERCISES
OCCUPATIONAL THERAPY
REHABILITATION- BRACES.

24. • REPAIR OF DAMAGED JOINT
SYNOVECTOMY
• REPLACEMENT OF JOINT
THR, TKR

25. SERONEGATIVE SPONDYLOARTHRITIS
• ANKYLOSING SPONDYLITIS
• PSORIATIC ARTHRITIS
• REACTIVE ARTHRITIS

26. ANKYLOSING SPONDYLITIS
• Progressive inflammatory stiffening of the
joints.
• Axial skeleton
• Sacroiliac joint -> spine involved
• Idiopathic etiology
• Associated with HLA – B27

27. Pathology
• Synovitis
• Cartilage distruction
• Bony erosion
• Fibrosis
• Ankylosis
• Ossification in ALL STIFF SPINE

28. CLINICAL FEATURES
• Young adult
• Male
• Gradual onset of pain, stiffness lower back.
• Stiffness increases with rest
• Improves with movement
• Pain in heel

29. • Pain in pubic symphysis
• Pain in manubrium sterni
• Later stages – kyphotic deformity of spine.

30. Examination
• Straight stiff back (while walking)
• Loss of lumber lordosis
• Lumbar spine flexion limited

31. Sacroiliac joint involvement
• Tenderness – posterior superior iliac spine
• Sacroiliac compression – side to side pelvic
compression causes pain at SI joint
• Gaenslen’s test – hip and knee of opposite
side flexed to fix pelvis, hip of affected side
hyper extended, rotational strain over SI joint
causes pain.
• Pump handle test- flex hip and knee , bring it
to opposite shoulder, pain on affected SI joint.

33. Cervical spine involvement
• Fle’che test – heel and back
against wall, back of head
touching wall without raising
chin, inability of head to
touch the wall suggests
cervical spine involvement.
• Detects early involvement of
cervical spine.

34. Thoracic spine involvement
• Maximum chest expansion, from full
inspiration to full expiration at level of nipples
• Chest expansion less than 5 cm indicates costo
vertebral joints involvement

35. Extra articular manifestations
• Ocular – acute iritis, scarring, depigmentation of
iris.
• Cardiovascular- cardiomegaly, conduction defects
• Neurological- atlanto axial joint involvement,
trivial trauma may cause subluxation of joint and
spinal cord compression
• Pulmonary – costovertebral joint involement
causes painless diminished chest expansion
• Generalised osteoporosis

36. Investigations
• X ray PELVIS AP view
• Dorso lumbar spine AP and
lateral ( squaring of vertebrae,
bridging osteophytes,
bamboo spine appearance)
• Oblique view of sacroiliac
joint ( haziness, irregular
erosions, sclerosis , widening,
bony ankylosis of SI joint)

37. • Calcification of sacroiliac
ligament and sacrotuberous
ligaments
• Evidence of enthesopathy –
calcification at attachment of
muscles, tendons and
ligaments particularly around
pelvis and around heel.

38. Treatment
• Control pain – NSAIDS; INDOMETHACIN
• Maintain degree of joint mobility –
Physiotherapy;
• proper posture guidance,
• heat therapy,
• mobilisation exercises
• Operative – kyphotic deformity correction, joint
replacement for hip or knee joint replacement

39. GOUT
• Disturbed purine metabolism
• Hyperuricemia
• Sodium biurate crystals deposit
in cartilage, tendon, bursa.
• 40 yrs
• Males > females
• Acute severe pain MTP joint of
great toe

40. • Bursitis – olecranon
bursa
• Tophi formation- deposit
of uric acid in soft tissue

41. • Confirmation of diagnosis- urate crystals in
aspirate from a joint or bursa
• High serum uric acid level.
• Treatment
• NSAIDS
• URICOSURIC DRUGS - probenecid
• URIC ACID INHIBITORS – allopurinol,
febuxostat

42. PSEUDO GOUT
• Sodium pyrophosphate
crystal deposits
• Symptoms same as of gout
• Meniscus calcification seen
on x ray
• NSAIDS for symptomatic relief
• Allopurinol / febuxostat if
serum uric acid levels raised.

43. PSORIATIC ARTHROPATHY
• Polyarthritis
• Distal IP joints of hands
involved
• Classic skin and nail lesions
• Treatment - steroids

44. ALKAPTONURIC ARTHRITIS
• OCRONOSIS
• Phenylalanine and
tyrosine metabolic defect
• Homogentisic acid
excreted in urine
• Pigment deposits in sclera
• X ray – disc space
calcification
• Peri articular calcification
in large joint

45. HAEMOPHILIC ARTHRITIS
• Associated with bleeding
disorders
• Males
• Knee, elbow, ankle
• Acute/ chronic hemarthrosis
• X ray- non specific signs of bone
resorption, cyst formation,
osteoporosis, widening of
intercondylar notch in knee

46. Treatment
• Rest – acute phase
• Deficient factor replacement
• Chronic stages- physiotherapy, bracing

47. Neuropathic arthropathy
• Charcot’s joint/ neuropathic
joint
• Loss of sensation of joints
• Repeated strains on joint
• Severe degeneration of joint.
• Joint – painless effusion,
deformity, instability
• X ray – reduced joint space,
• Treatment- bracing supports

48. • THANK YOU SO MUCH